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Visual Dysfunctions and Traumatic Brain Injury

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Visual Dysfunctions and Traumatic Brain Injury Visual Dysfunctions and Traumatic Brain Injury Felix M. Barker II, OD; DoD/VA Vision Center of Excellence (VCE) Natalya (Natasha) Merezhinskaya, PhD; DoD/VA Vision Center of Excellence (VCE) “Medically Ready Force…Ready Medical Force” UNCLASSIFIED Poll question Choose one answer • Which occupational area best describes your TBI- related practice? o Primary Care o Physical Medicine o PT/OT o Eye Care o Vision Rehabilitation “Medically Ready Force…Ready Medical Force” 2 UNCLASSIFIED TBI Statistics ∎ In 2014,1 about 2.87 million TBI-related emergency department (ED) visits, hospitalizations, and deaths occurred in the United States ∎ From 2006 to 2014, the number of TBI-related emergency department visits, hospitalizations, and deaths increased by 53%. 1 Centers for Disease Control and Prevention (2019). Surveillance Report of Traumatic Brain Injury-related Emergency Department Visits, Hospitalizations, and Deaths—United States, 2014. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. “Medically Ready Force…Ready Medical Force” 3 UNCLASSIFIED DoD TBI Totals Worldwide 2000-2018 https://dvbic.dcoe.mil/dod-worldwide-numbers-tbi “Medically Ready Force…Ready Medical Force” 4 UNCLASSIFIED Visual Deficits and Dysfunctions Associated with Traumatic Brain Injury: A Systematic Review and Meta-Analysis Natalya Merezhinskaya, PhD, Rita K. Mallia, OD, MPA, DoHwan Park, PhD, Daniel W. Bryden, PhD, Karan Mathur, and Felix M. Barker II, OD, MS, FAAO Optom Vis Sci. 2019 Aug;96(8):542-555 “Medically Ready Force…Ready Medical Force” 5 UNCLASSIFIED Objectives To conduct a systematic review and meta-analysis to determine the prevalence rates of accommodative dysfunction, convergence insufficiency, visual field loss, and visual acuity loss in TBI patients without concomitant eye injury. “Medically Ready Force…Ready Medical Force” 6 UNCLASSIFIED Literature Review vs Systematic Review Literature Review Systematic Review Study question can be general and not well Study question is well defined and focused defined Publications are searched randomly, “pick Publications are searched using established and choose” approach; using only few methodology; using several large databases databases Papers are reviewed without any procedural Publications are reviewed using an restrictions established procedure; strict inclusion and exclusion criteria are applied; two or more researchers to establish inter-rater reliability A writer gives a subjective interpretation of Data is analyzed using referenced the data methodology; the bias, strength of evidence, etc. are considered in the analysis “Medically Ready Force…Ready Medical Force” 7 UNCLASSIFIED Meta-Analysis ∎ Meta-analysis is a set of techniques used “to combine the results of a number of different reports into one report to create a single, more precise estimate of an effect” (Ferrer, 1998). The aims of meta-analysis are “to increase statistical power; to deal with controversy when individual studies disagree; to improve estimates of size of effect, and to answer new questions not previously posed in component studies” (Hunter and Schmidt, 1990) “Medically Ready Force…Ready Medical Force” 8 UNCLASSIFIED Inclusion and Exclusion Criteria Inclusion Criteria Exclusion criteria TBI diagnosis by a trained medical Single case designs professional Screening/diagnostic testing for visual The sample population artificially selected dysfunctions by an eye care provider for one of the visual outcomes Published in English in a peer-reviewed The sample population previously journal with full text available diagnosed with a chronic (or other) eye condition Accommodation was measured in non- Brain injury unrelated to trauma presbyopic TBI populations TBI and/or visual outcomes were self- reported or otherwise not clinically diagnosed “Medically Ready Force…Ready Medical Force” 9 UNCLASSIFIED Flow diagram of the systematic literature search process according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Publications identified through database searching Additional publications • PubMed (n = 1,068) identified through other • EMBASE (n = 2,716) sources and bibliographies (n • EBSCO (n = 131) = 364) Identification • Cochrane Library (n = 232) Publications after duplicates removed (n = 2,104) Screening Publications screened for Publications excluded (n = relevance using title/abstract 1,342) (n = 2,104) Full-text publications excluded, with reasons (n =740) Full-text publications .Non-TBI sample population (n = 296) Eligibility assessed for eligibility (n = .Relevant visual conditions not measured (n = 762) 324) .An article that did not present original data (n= 98) .Manuscript in a foreign language (n = 3) .Sample population selected for visual outcome Publications included in (n=4) Included quantitative meta-analysis .Sample population examined by non-eye care (n =22) provider (n=15) “Medically Ready Force…Ready Medical Force” 10 UNCLASSIFIED Statistical Analysis . All statistical analyses were conducted using R statistical software (3.4.2) and its ‘meta’ and ‘metafor’ package. Prevalence rates were calculated by dividing the number of individuals with TBI diagnosed with the visual outcome by the total number of individuals diagnosed with TBI. Subgroup analysis was performed for four moderators: (1) study design (prospective versus retrospective) (2) TBI severity (3) diagnostic criteria and (4) Risk of Bias (RoB) “Medically Ready Force…Ready Medical Force” 11 UNCLASSIFIED Prevalence of Visual Dysfunctions in TBI Patients Visual Accommodative Convergence Visual Field Loss Visual Acuity dysfunction Dysfunction Insufficiency Total patient 1,271 2,140 2, 106 1,333 count Prevalence 42.85% 36.3% 18.2% 0% 95% CI 31.1-54.7 28.2 – 44.9 10.6 – 27.1 0.0 – 1.1 Heterogeneity,I2 91.35% 89.94% 92.67% 62.2% Prevalence, no 5.8% – 32.4% 4.2% – 31.4% 0% - 3% <1% TBI control (lit.) “Medically Ready Force…Ready Medical Force” 12 UNCLASSIFIED Prevalence of Visual Field Loss in Moderate- to-Severe TBI Compared to Mild TBI TBI Severity Moderate to Severe TBI Mild TBI Prevalence 39.8% 6.6% 95% CI 29.8 – 50.3 6.9 – 34.2 . The prevalence of accommodative dysfunction and convergence insufficiency did not differ in patients with moderate-to-severe compared to mild TBI . Only one study of moderate-to-severe TBI data was available for accommodative dysfunction “Medically Ready Force…Ready Medical Force” 13 UNCLASSIFIED Other Moderating Variables and Their Relationship with Visual Outcome Prevalence . In addition to TBI severity, the studies were evaluated on the association of the prevalence rates with RoB, diagnostic criteria, and study design (prospective versus retrospective) . No singular factor accounted for a statistically significant portion of the heterogeneity . The screening/diagnostic criteria for the visual dysfunctions varied significantly between different studies (e.q. diagnostic cut offs for the NPC varied from 6-12.7 cm) . Many studies had incomplete data on the demographics, TBI severity, mechanism of injury, etc. “Medically Ready Force…Ready Medical Force” 14 UNCLASSIFIED Conclusions . Accommodative dysfunction and convergence insufficiency are the most prevalent of the four visual outcomes examined in this study, followed by the visual field loss. The relatively low prevalence of visual acuity loss due to neurologic consequences of TBI and in the absence of eye injury suggests that the test for visual acuity, the most commonly performed measure of the visual system, is an insufficient stand-alone surrogate for overall visual health. Heterogeneity was one of the major limitations of this study with no one single factor but rather a combination of several factors responsible for it. A carefully constructed prospective trial with a large sample and consistent evaluation techniques will have a tremendous impact on the field and will address the various limitations outlined above. “Medically Ready Force…Ready Medical Force” 15 UNCLASSIFIED Poll question Choose one answer ∎ What is your knowledge and skill level regarding post-TBI eye/vision-related effects? o Exclusively o Heavily o Occasionally o Rarely o Never “Medically Ready Force…Ready Medical Force” 16 UNCLASSIFIED Clinical Impact- Near Distance Visual Dysfunctions ∎ Accommodation and Convergence are frequently affected after TBI of any severity and have the potential to affect reading and other near visual tasks Accommodative Dysfunction (AD) affects focusing to reading and other near target distances. https://www.dvidshub.net/image/5576874/usns-comfort-crew-treats- Convergence Insufficiency (CI) patients-peru-medical-sites reduces the ability to turn the eyes inwardly to near (reading) distances, thus affecting ability to maintain single vision at near. “Medically Ready Force…Ready Medical Force” 17 UNCLASSIFIED Symptoms of Near Visual Dysfunctions ∎ Visual blurring at near visual distances ∎ Doubling of vision at near visual distances ∎ Losing your place while reading ∎ Inability to sustain reading and other near visual tasks https://www.dvidshub.net/search/?q=5737568&view=grid ∎ Sensitivity to light “Medically Ready Force…Ready Medical Force” 18 UNCLASSIFIED TBI-related Visual Dysfunctions Can Affect Rehabilitation and Reintegration ∎ Because visual acuity is usually normal after TBI, patients may often be unaware of visual dysfunctions and attribute difficulties with reading and other symptoms to co-morbid conditions, such as PTSD, or psychosocial factors. ∎ Referral to an Eye Care Provider can help manage
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